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End-artery vessels arise from the tery which contains the superior mesenteric vessels buy 260mg extra super avana mastercard, lymphatics and auto- arcades to supply the gut wall effective extra super avana 260mg. The origin of the mesentery measures approximately 15 sists of few arcades and little terminal branching whereas the vessels to cm and passes from the duodenojejunal flexure to the right sacro-iliac the ileum form numerous arcades and much terminal branching of end- joint. No sharp distinction occurs between the jejunum and ileum; however, certain characteristics help distinguish between them: Small bowel obstruction (Fig. Loops of jejunum tend to occupy the umbilical region adhesions and herniae are the most frequent causes. In the pelvic position the appendix may be close to the ovary in the female Longitudinal muscle Circular muscle Rectum Levator ani Obturator internus Fat of ischiorectal fossa Sphincter Deep Submucosa ani Superficial Sphincter ani internus externus Subcutaneous Pudendal canal Adductor muscles Inferior rectal vesels and nerve Fig. It commences in front of ascending, transverse, descending and sigmoid colon have similar the 3rd sacral vertebra as a continuation of the sigmoid colon and fol- characteristic features. The teniae coli fan out over the rec- course from the base of the appendix (and form a useful way of locating tum to form anterior and posterior bands. These sacculations are visible • Peritoneum covers the upper two-thirds of the rectum anteriorly but not only at operation but also radiographically. In the female it is reflected forwards onto ray, the colon, which appears radiotranslucent because of the gas within, the uterus forming the recto-uterine pouch (pouch of Douglas). They are adherent to the posterior The anorectal junction is slung by the puborectalis component of lev- abdominal wall and covered only anteriorly by peritoneum. This is the site where the The appendix varies enormously in length but in adults it is approxim- proctodeum (ectoderm) meets endoderm. The base of the appendix arises from the postero- tion is reflected by the following characteristics of the anal canal: medial aspect of the caecum; however, the lie of the appendix itself is • The epithelium of the upper half of the anal canal is columnar. In most cases the appendix lies in the retrocaecal posi- trast the epithelium of the lower half of the anal canal is squamous. The appendix has the follow- mucosa of the upper canal is thrown into vertical columns (of Mor- ing characteristic features: gagni). The only blood supply to the appendix, the appendicular artery (a • The blood supply to the upper anal canal (see Fig. In superior rectal artery (derived from the inferior mesenteric artery) cases of appendicitis the appendicular artery ultimately thromboses. The lower anal canal is sensitive to pain as it is sup- • The bloodless fold of Treves (ileocaecal fold) is the name given to a plied by somatic innervation (inferior rectal nerve). Most surgeons still opt to invaginate the appendix stump as a precau- tionary measure against slippage of the stump ligature. The lower gastrointestinal tract 43 18 The liver, gall-bladder and biliary tree Opening in central tendon of diaphragm Hepatic vein Liver Spleen Portal vein Splenic vein Inferior mesenteric vein Superior mesenteric vein Fig. The transmission of blood from the portal system to the inferior vena cava is via the liver lobules (fig. The extensive length of gut that is surface is related to the diaphragm and its lower border follows the con- drained by the portal vein explains the predisposition for intestinal tour of the right costal margin. These are separated antero-superiorly by the falciform ligament The gall-bladder lies adherent to the undersurface of the liver in the and postero-inferiorly by fissures for the ligamentum venosum and liga- transpyloric plane (p. In the anatomical classification the right lobe includes The duodenum and the transverse colon are behind it. Functionally, however, the caudate and The gall-bladder acts as a reservoir for bile which it concentrates. Hence, the functional classification of the liver defines response to gall-bladder contraction induced by gut hormones. There is, how- • Left anterior limbathe fissure containing the ligamentum teres ever, no corresponding cystic vein but venous drainage occurs via (the fetal remnant of the left umbilical vein which returns oxygen- small veins passing through the gall-bladder bed. The caudate and quadrate courses, sequentially, in the free edge of the lesser omentum, behind the lobes of the liver are the areas defined above and below the hori- first part of the duodenum and in the groove between the second part of zontal bar of the H, respectively. Cholelithiasis • The liver is covered by peritoneum with the exception of the ‘bare Gallstones are composed of either cholesterol, bile pigment, or, more area’. Most gallstones are asymptomatic; however, portal canals into a central vein by way of sinusoids which traverse the when they migrate down the biliary tree they can be responsible for a lobules. The central veins ultimately coalesce into the right, left and diverse array of complications such as: acute cholecystitis, biliary central hepatic veins which drain blood from corresponding liver areas colic, cholangitis and pancreatitis. The portal canals also contain tributaries of the The liver, gall-bladder and biliary tree 45 19 The pancreas and spleen Inferior vena cava Coeliac artery Portal vein Left gastric artery Common bile duct Hepatic artery Right gastric artery Splenic artery Gastroduodenal artery Right gastroepiploic artery Superior pancreaticoduodenal artery Inferior pancreaticoduodenal artery Inferior mesenteric artery and vein Superior mesenteric artery and vein Fig. It is a retroperitoneal The spleen is approximately the size of a clenched fist and lies directly organ which lies roughly along the transpyloric plane. The head is below the left hemidiaphragm which, in addition to the pleura, separ- bound laterally by the curved duodenum and the tail extends to the ates it from the overlying 9th, 10th and 11th ribs. The superior mesenteric • Peritoneal attachments: the splenic capsule is fibrous with peri- vessels pass behind the pancreas, then anteriorly, over the uncinate toneum adherent to its surface. The gastrosplenic and lienorenal liga- process and third part of the duodenum into the root of the small bowel ments attach it to the stomach and kidney, respectively. The inferior vena cava, aorta, coeliac plexus, left kidney ligament carries the short gastric and left gastroepiploic vessels to the (and its vessels) and the left adrenal gland are posterior pancreatic rela- fundus and greater curvature of the stomach, and the latter ligament tions. In addition, the portal vein is formed behind the pancreatic neck carries the splenic vessels and tail of the pancreas towards the left by the confluence of the splenic and superior mesenteric veins. The splenic artery Splenectomy courses along the upper border of the body of the pancreas which it sup- As the spleen is a highly vascular organ, any injury to it can be life- plies by means of a large branchathe arteria pancreatica magnaaand threatening. The technique used differs slightly when the procedure is • Function: the pancreas is a lobulated structure which performs both performed for emergency as opposed to elective indications, but the exocrine and endocrine functions. Splenectomy involves: ligature of the splenic pancreatic juice into the pancreatic ducts and, from there, ultimately vessels approaching the hilum (taking care not to injure the tail of the into the duodenum. The secretion is essential for the digestion and pancreas or colon); and dissection of the splenic pediclesbthe gastro- absorption of proteins, fats and carbohydrates. The mechanism by all patients are routinely vaccinated against the capsulated bacteria, which these aetiological factors result in pancreatic injury is unknown; and children, who are the group most at risk of sepsis, are maintained however, they both appear to result in activation of pancreatic exocrine on long-term antibiotic prophylaxis.

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Purpose 99 Basic Clinical Nursing Skills Sputum specimen usually collected for: • Culture and sensitivity test (i generic extra super avana 260mg overnight delivery. Patient preparation • Before collecting sputum specimen buy extra super avana 260mg with amex, teach pt about the difference between sputum and saliva, how to cough deeply to raise sputum. Obtain sputum specimen 100 Basic Clinical Nursing Skills • Put on gloves, to avoid contact with sputum particularly it hemoptysis (blood in sputum) present. Recomfort the patient • Give oral care following sputum collection (To remove any unpleasant taste) 4. Care of the specimen and the equipments used • Label the specimen container • Arrange or send the specimen promptly and immediately to laboratory. Document the amount, color, consistency of sputum, (thick, watery, tenacious) and presence of blood in the sputum. Collecting Blood Specimen 101 Basic Clinical Nursing Skills The hospital laboratory technicians obtain most routine blood specimens. Patient preparation 102 Basic Clinical Nursing Skills • Instruct the pt what to expect and for fasting (if required) • Position the pt comfortably 2. Obtain specimen of the venous to blood • Adjust the syringe and needles • Clean/disinfect the area with alcohol swab, dry with sterile cotton swab • Puncture the vein sites • Release the tourniquet when you are sure in the vein • Withdraw the required amount of venous blood specimen 103 Basic Clinical Nursing Skills • Withdraw the needle and hold the sites with dry cotton (to apply pressure) • Put the blood into the specimen container • Made sure not to contaminate outer part of the container and not to distract the blood cells while putting it into the container 4. Care of the specimen and the equipment • Label the container • Shake gently (if indicated to mix) • Send immediately to laboratory, accompanying the request • Give care of used equipments 6. Chart Definition: it is a written record of history, examination, tests, diagnosis, and prognosis response to therapy Purpose of Patients Chart a. For diagnosis or treatment of a patient while in the hospital (find after discharge) if patient returns for treatment in the future time b. For serving an information in the education of health personnel (medical students, interns, nurses, dietitians, etc) e. For promoting public health General Rules for Charting • Spelling Make certain you spell correctly 105 Basic Clinical Nursing Skills • Accuracy Records must be correct in all ways, be honest • Completeness No omission, avoid unnecessary words or statement • Exactness Do not use a word you are not sure of • Objective information Record what you see avoid saying (condition better) • Legibility Print/write plainly and distinctively as possible • Neatness No wrinkles, proper speaking of items Place all abbreviation, and at end of statement • Composition / arrangement Chart carefully consult if in doubt avoid using of chemical formulas • Sentences need to be complete and clear, avoid repetition • Don’t overwrite • Don’t leave empty spaces in between • Time of charting Specific time and date • Color of ink Black or blue (red for transfusion, days of surgery) 106 Basic Clinical Nursing Skills It should be recorded on the graphic sheet All orders should be written and signed. Verbal or telephone orders should be taken only in emergency verbal orders should be written in the order sheet and signed on the next visit. Laboratory and other diagnostic reports • Patients or relatives and friends of patients are not allowed to read the chart when necessary but can have access if allowed by patient. Purpose: • To replace fluid losses 107 Basic Clinical Nursing Skills • To provide maintenance requirements • To check for retention of body fluid Fluid balance sheet ♦ 24 hrs the intake out put should be compared and the balance is recorded ¾ Positive balance if intake >output Negative balance if out put >intake Study Questions 1. Closed bed: is a smooth, comfortable and clean bed, which is prepared for a new patient • In closed bed: the top sheet, blanket and bed spread are drawn up to the top of the bed and under the pillows. Open bed: is one which is made for an ambulatory patient are made in the same way but the top covers of an open bed are folded back to make it easier of a client to get in. To conserve patient’s energy and maintain current health status 110 Basic Clinical Nursing Skills Anesthetic bed: is a bed prepared for a patient recovering from anesthesia ⇒ Purpose: to facilitate easy transfer of the patient from stretcher to bed Amputation bed: a regular bed with a bed cradle and sand bags ⇒ Purpose: to leave the amputated part easy for observation Fracture bed: a bed board under normal bed and cradle ⇒ Purpose: to provide a flat, unyielding surface to support a fracture part Cardiac bed: is one prepared for a patient with heart problem ⇒ Purpose: to ease difficulty in breathing General Instructions 1. Linen for one client is never (even momentarily) placed on another client’s bed 111 Basic Clinical Nursing Skills 5. Soiled linen is placed directly in a portable linen hamper or a pillow case before it is gathered for disposal 6. Soiled linen is never shaken in the air because shaking can disseminate secretions and excretions and the microorganisms they contain 7. When stripping and making a bed, conserve time and energy by stripping and making up one side as completely as possible before working on the other side 8. To avoid unnecessary trips to the linen supply area, gather all needed linen before starting to strip bed 9. Vertical - make a fold in the sheet 5-10 cm 1 to the foot Horizontal – make a fold in the sheet 5-10 cm across the bed near the foot 10. Bed spread Note • Pillow should not be used for babies • The mattress should be turned as often as necessary to prevent sagging, which will cause discomfort to the patient. Closed Bed • It is a smooth, comfortable, and clean bed that is prepared for a new patient Essential Equipment: • Two large sheets • Rubber draw sheet • Draw sheet • Blankets • Pillow cases • Bed spread Procedure: • Wash hands and collect necessary materials • Place the materials to be used on the chair. Turn mattress and arrange evenly on the bed • Place bottom sheet with correct side up, center of sheet on center of bed and then at the head of the bed 113 Basic Clinical Nursing Skills • Tuck sheet under mattress at the head of bed and miter the corner • Remain on one side of bed until you have completed making the bed on that side • Tuck sheet on the sides and foot of bed, mitering the corners • Tuck sheets smoothly under the mattress, there should be no wrinkles • Place rubber draw at the center of the bed and tuck smoothly and tightly • Place cotton draw sheet on top of rubber draw sheet and tuck. The rubber draw sheet should be covered completely • Place top sheet with wrong side up, center fold of sheet on center of bed and wide hem at head of bed • Tuck sheet of foot of bed, mitering the corner • Place blankets with center of blanket on center of bed, tuck at the foot of beds and miter the corner • Fold top sheet over blanket • Place bed spread with right side up and tuck it • Miter the corners at the foot of the bed • Go to other side of bed and tuck in bottom sheet, draw sheet, mitering corners and smoothening out all wrinkles, put pillow case on pillow and place on bed • See that bed is neat and smooth • Leave bed in place and furniture in order • Wash hands 114 Basic Clinical Nursing Skills B. Occupied Bed Purpose: to provide comfort, cleanliness and facilitate position of the patients Essential equipment: • Two large sheets • Draw sheet • Pillow case • Pajamas or gown, if necessary Procedure: • If a full bath is not given at this time, the patient’s back should be washed and cared for • Wash hands and collect equipment • Explain procedure to the patient • Carry all equipment to the bed and arrange in the order it is to be used • Make sure the windows and doors are closed • Make the bed flat, if possible • Loosen all bedding from the mattress, beginning at head of the bed, and place dirty pillow cases on the chair for receiving dirty linen • Have patient flex knees, or help patient do so. With one hand over the patient’s shoulder and the shoulder hand over the patient’s knees, turn the patient towards you 115 Basic Clinical Nursing Skills • Never turn a helpless patient away from you, as this may cause him/her to fall out bed • When you have made the patient comfortable and secure as near to the edge of the bed as possible, to go the other side carrying your equipment with you • Loosen the bedding on that side • Fold, the bed spread half way down from the head • Fold the bedding neatly up over patient • Roll dirty bottom sheet close to patient • Put on clean bottom sheet on used top sheet center, fold at center of bed, rolling the top half close to the patient, tucking top and bottom ends tightly and mitering the corner • Put on rubber sheet and draw sheet if needed • Turn patient towards you on to the clean sheets and make comfortable on the edge of bed • Go to the opposite side of bed. Taking basin and wash cloths with you, give patient back care • Remove dirty sheet gently and place in dirty pillow case, but not on the floor • Remove dirty bottom sheet and unroll clean linen • Tuck in tightly at ends and miter corners • Turn patient and make position comfortable • Back rub should be given before the patient is turned on his /her back • Place clean sheet over top sheet and ask the patient to hold it if she/he is conscious 116 Basic Clinical Nursing Skills • Go to foot of bed and pull the dirty top sheet out • Replace the blanket and bed spread • Miter the corners • Tuck in along sides for low beds • Leave sides hanging on high beds • Turn the top of the bed spread under the blanket • Turn top sheet back over the blanket and bed spread • Change pillowcase, lift patient’s head to replace pillow. Loosen top bedding over patient’s toes and chest • Be sure the patient is comfortable • Clean bedside table • Remove dirty linen, leaving room in order Wash hands Bed Making Making a post operative bed o The entire bed need clean linen. Fanfold the top linens to the side so that they lay opposite from where you will place the client’s stretcher. Rational: A pillow may be contraindicated for a client, usually the physician or charge nurse will determine when it is safe for the client to have one. Mouth Care Purpose • To remove food particles from around and between the teeth • To remove dental plaque to prevent dental caries • To increase appetite • To enhance the client’s feelings of well-being • To prevent sores and infections of the oral tissue • To prevent bad odor or halitosis Equipments • Toothbrush (use the person’s private item. If patient has none use of cotton tipped applicator and plain water) • Tooth paste (use the person’s private item. If patient has none of use cotton tipped applicator and plain water) • Cup of water • Emesis basin • Towel • Denture bowel (if required) • Cotton tipped applicator, padded applicator • Vaseline if necessary Procedure 1. Prepare the pt: • Explain the procedure 121 Basic Clinical Nursing Skills • Assist the patient to a sitting position in bed (if the health condition permits). Brush the teeth • Moisten the tooth with water and spread small amount of tooth paste on it • Brush the teeth following the appropriate technique. Recomfort the pt • Remove the basin • Remove the towel • Assist the patient in wiping the mouth 122 Basic Clinical Nursing Skills • Reposition the patient and adjust the bed to leave patient comfortably 3.

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Once peak plasma concentrations have been attained generic extra super avana 260 mg without prescription, the concentration of the active metabolite declines with an apparent half-life of 6 to 10 hours (He 1999) buy extra super avana 260mg amex. In patients with renal impairment, metabolite clearance decreases linearly with creatinine clearance, and averages 23 h after oral administration in individuals with a creatinine clear- ance < 30 ml/min (Doucette 2001). A dosage reduction to 75 mg once daily is rec- ommended for patients with a creatinine clearance < 30 ml/min (1. The drug and the active metabolite are excreted by glomerular filtration and active tubular secretion without further metabolism (Hill 2001). Neither compound interacts with cytochrome P450 mixed-function oxidases or glucuronosyltransferases (He 1999). Thus, the potential is low for drug-drug in- teractions, which appear to be limited to those arising from competitive inhibition of excretion by the renal tubular epithelial cell anionic transporter. Probenecid blocks the renal secretion of oseltamivir, more than doubling systemic exposure oseltamivir carboxylate (Hill 2002). This competition is unlikely to be clinically 196 Drug Profiles relevant, but there has been speculation about using probenecid to “stretch” osel- tamivir stocks in situations of pandemic shortage (Butler 2005). The metabolism of oseltamivir is not compromised in hepatically impaired patients and no dose adjustment is required (Snell 2005). In elderly individuals, exposure to the active metabolite at steady state is approxi- mately 25 % higher compared with young individuals; however, no dosage adjust- ment is necessary (He 1999). Young children 1 to 12 years of age clear the active metabolite oseltamivir car- boxylate at a faster rate than older children and adults, resulting in lower exposure. Increasing the dose to 2 mg/kg twice daily resulted in drug exposures comparable to the standard 1 mg/kg twice daily dose used in adults (Oo 2001). Toxicity The most frequent side effects are nausea and vomiting which are generally of a mild to moderate degree and usually occur within the first 2 days of treatment. In many cases, it is not possible to reliably estimate their frequency or establish a cause relationship to oseltamivir exposure:! Aggravation of diabetes Oseltamivir use does not appear to be associated with an increased risk of skin re- actions (Nordstrom 2004); however, anecdotal reports describe isolated skin reac- tions, i. The use of oseltamivir in infants younger than 1 year is not recommended as studies on juvenile rats revealed potential toxicity of oseltamivir for this age group. Moreo- ver, high drug levels were found in the brains of 7-day-old rats which were exposed to a single dose of 1,000 mg/kg oseltamivir phosphate (about 250 times the recom- mended dose in children). Further studies showed the levels of oseltamivir phos- phate in the brain to be approximately 1,500 times those seen in adult animals. How- ever, given the uncertainty in predicting the exposure in infants with immature blood-brain barriers, it is recommended that oseltamivir not be administered to children younger than 1 year, the age at which the human blood-brain barrier is generally recognised to be fully developed (Dear Doctor-Letter, http://InfluenzaReport. Oseltamivir 197 Oseltamivir is a pregnancy category C drug, as there are insufficient human data upon which to base a risk evaluation of oseltamivir to the pregnant woman or de- veloping foetus. In lactating rats, oseltamivir is excreted in the milk, but oseltamivir has not been studied in nursing mothers and it is not known, if oseltamivir is excreted in human milk. After reports of psychological disorders in patients treated with oseltamivir, Japa- nese authorities have amended the patient information to list psychiatric effects, such as delusions, in the list of side effects. Efficacy Treatment Oseltamivir, 75 mg bid for 5 days, administered to otherwise healthy adults with naturally acquired febrile influenza when started within 36 hours of the onset of symptoms, reduced the duration of the disease by up to 1. Earlier initiation of therapy was associated with a faster resolution: initiation of therapy within the first 12 h after fever onset reduced the total median illness duration 3 days more than intervention at 48 h. In addition, the earlier administration of oseltamivir reduced the duration of fever, severity of symptoms and the times to return to baseline activity (Aoki 2003). A meta-analysis of 10 placebo-controlled, double-blind trials suggests that oseltamivir treatment of influenza illness reduces lower respira- tory tract complications, use of antibacterials, and hospitalisation in both healthy and “at-risk” adults (Kaiser 2003). The efficacy and safety of oseltamivir in patients with chronic respiratory diseases (chronic bronchitis, obstructive emphysema, bronchial asthma or bronchiectasis) or chronic cardiac disease has not been well defined. In one small randomised trial oseltamivir significantly reduced the incidence of complications (11 % vs. Oseltamivir treatment may be less effective for influenza B than for influenza A (for efficacy against H5N1 strains, see below). A cost-utility decision model, including epidemiological data and data from clinical trials of antiviral drugs, concluded that for unvaccinated or high-risk vaccinated patients, empirical oseltamivir treatment seems to be cost-effective during the influ- enza season, while for other patients, treatment initiation should await the results of rapid diagnostic testing (Rothberg 2003). Prophylaxis When used in experimentally infected individuals, prophylactic use of oseltamivir resulted in a reduced number of infections (8/21 in the placebo group and 8/12 in the oseltamivir group) and infection-related respiratory illness (4/12 vs. These findings were confirmed by a clinical trial in 1,559 healthy, non-immunised adults aged 18 to 65 years, who received either 198 Drug Profiles oral oseltamivir (75 mg or 150 mg daily) or placebo for six weeks during a peak period of local influenza activity (Hayden 1999b). A meta-analysis of seven prevention trials showed that pro- phylaxis with oseltamivir reduced the risk of developing influenza by 70-90 % (Cooper 2003). A cost-effectiveness analysis based on a decision analytic model from a govern- ment-payer perspective calculated that the use of oseltamivir post-exposure pro- phylaxis is more cost-effective than amantadine prophylaxis or no prophylaxis (Risebrough 2005). Another recent meta-analysis, however, found a relatively low efficacy of oseltamivir (Jefferson 2006), leading the authors to conclude that osel- tamivir should not be used in seasonal influenza control and should only be used in a serious epidemic and pandemic alongside other public health measures. Selected Patient Populations A double-blind, placebo-controlled study investigated the efficacy of once-daily oral oseltamivir for 6 weeks as a prophylaxis against laboratory-confirmed clinical influenza in 548 frail older people (mean age 81 years, > 80 % vaccinated) living in homes for seniors (Peters 2001). Compared with placebo, oseltamivir resulted in a 92 % reduction in the incidence of laboratory-confirmed clinical influenza (1/276 = 0. Children: oral oseltamivir treatment in paediatric patients reduced the median du- ration of illness by 36 h and also cough, coryza and duration of fever. In addition, new diagnoses of otitis media were reduced by 44 % and the incidence of physi- cian-prescribed antibiotics was lower (Whitley 2001).

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